Purpose: To ensure the accurate recording of patient medical history, diagnostic imaging, and dental status within CareStack to facilitate a precise diagnosis by the provider.
1. Clinical Summary Review
Purpose: The Clinical Summary feature provides a centralized view of the patient’s current treatment and medical information. Reviewing this information before seating the patient allows the clinical team to identify allergies, medical conditions, medications, and appointment-related details prior to treatment.
From the Scheduler, right-click the appointment and navigate to View Dental Chart where your clinical flow begins. Select the Clinical Summary right above the Care Panel.
Review the most current medical conditions, allergies and current medications on the top right-hand side. You can also filter for older copies of medical histories to see any recent changes.
Any prescription information the office has previously documented for the patient will be visible, along with upcoming Recall appointments, Care Notes and Lab Cases.
Treatment: The clinical summary at the bottom will also indicate how much existing and completed treatment the patient has had with your practice. You can also easily view the history of previously completed x-rays and which codes are being considered in the clinical summary number.
2. Medical History Review
Before clinical intake begins, verify the patient’s information and health history to ensure safety. The patients' completed answers are available from the patient overview. These should be reviewed with the patient to ensure nothing was forgotten or incorrectly entered. Once a provider signs:
Access Alerts: Navigate to the left navigation panel and check the Med. Hx. section, which will have an alert icon if there are unsigned forms from the patient. This is auto-populated from the information the patient initially provided at check-in.
Verification: Verbally review the patient’s responses, paying close attention to conditions, allergies, and current medication sections, as the answers will populate the Medical Alert section for easy reference.
Provider Signature: Capture the provider's signature at the time of the exam to prevent oversight from certain conditions that can impact the patient's care. Navigate to the last page of the medical history form and select the correct provider then click Add Signature. Click Print and Sign to finalize the form.
3. Diagnostic Imaging
Accurate charting and diagnosis that require diagnostic imaging.
Navigation: From the Patient Overview, go to Clinical > Chart.
Launch Imaging: Click the Imaging tab. Select Images and click Acquire New Exam.
Capture Images: Inside the Aeka window, click Acquire Exam. Here you can select from preset Templates that best fit the imaging needed. (full comprehensive series, bitewing, etc.) The imaging slots will automatically progress to the next slot upon capturing the image.
Saved Exam: Once all images are captured and saved, they will become visible within the Images Tab inside CareStack. You will be able to filter to the full exam view or an individual view.
To learn more:
4. Existing Conditions & Odontogram
Charting existing restorations and conditions is the "baseline" of the patient record and is key to having a comprehensive patient record.
Tooth Status (Primary vs. Permanent)
Highlight the specific teeth on the Odontogram.
Click the Tooth Symbol (left side of the Odontogram).
Select the appropriate status to toggle between Primary, Permanent or Unerupted.
Recording Existing Treatment
Care Panel: Located on the right side of the screen.
Toggle to "EXISTING": Ensure the EXISTING tab is selected to prevent existing conditions from being incorrectly charted as planned or completed treatment.
Entry: Select the applicable teeth, then use the Care Panel buttons or use the +Code button to search for less common procedures.Pro Tip: You can configure the Care Panel in Practice Settings or filter by Panel Type to show only the buttons you use on a regular basis. To learn more: https://carestack.zendesk.com/hc/en-us/articles/26795151665812-Utilize-the-Care-Panel-Feature#:~:text=New%20Care%20Panel-,Type,-To%20add%20a
5. Periodontal Charting (If Required)
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Navigation: Clinical Tab > Perio Chart.
Initiate: Click Add Chart and verify the Provider and Location.
Sequence: The cursor defaults to Pocket Depth (PD) starting at your preferred default setting for Practice Providers and Perio Charting Preferences. Missing teeth are automatically greyed out based on the Odontogram.
| PD | Pocket Depth
| SUP | Suppuration (shortcut: enter “s” on keyboard)
| GM | Gingival Margin
| PL | Plaque
| MGJ | Mucogingival Junction
| FUR | Furcation
| BOP | Bleeding on Probing (shortcut: enter “b” on keyboard)
| MOB | Mobility
Additional periodontal conditions can be entered using the Conditions options located in the bottom-right corner of the screen.
Save: Click Finish in the bottom-right corner to timestamp and lock the exam. Once this is saved, no edits can be made, and it is a permanent part of the patient record.
6. Charting Planned Treatment (Provider Diagnosis)
Once the provider has performed the exam, record the recommended treatment. Navigate back to the Chart and use the Care Panel again on the right-hand side to start documenting the treatment as prescribed by the provider.
Providers: Use the filter at the top to verify the provider performing the treatment. This mandatory step ensures the correct provider is assigned to each treatment entry. (The default provider in the patient’s overview will be automatically selected for you.)
Treatment Type: Should now be in the Planned stage.
Multi-Tooth Entry: To apply the same treatment to multiple teeth (e.g., 4 Quads of SRP or multiple fillings), highlight all applicable teeth first (dragging a box around selected teeth will automatically select the group of teeth). Next, click the treatment button in the Care Panel. Any codes that require additional information will appear with a red exclamation point next to the code. All necessary information must be entered in order to save the treatment to the chart.
Required Information: If a code requires a surface, material, or shade, a pop-up window will appear automatically. Complete all required fields to save the entry. If there are multiple teeth that have the same surface or quadrant assigned, click Apply for All to add to all highlighted teeth.
Final Review: Once all treatment has been entered, review the chart carefully to confirm accuracy and completeness before concluding the appointment.
To learn more about customizing your chart filters:
An Overview of Practice Settings for Chart Filters